Inspection Reports for Lutheran Life Villages – The Village at Anthony Boulevard
IN, 46816
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 20, 2025, identified deficiencies related to failure to protect a resident from abuse involving unauthorized medication and unsafe food given by the resident’s spouse. Earlier inspections also noted issues with abuse prevention, timely reporting, wound care, medication management, and communication with healthcare providers, as well as care plan deficiencies related to falls, dementia care, and acute condition management. Complaint investigations included substantiated findings of inadequate supervision, failure to follow advance directives, and insufficient dementia services, while most complaints were substantiated rather than unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The pattern of deficiencies suggests ongoing challenges in resident protection and individualized care, with no clear improvement trend over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
12% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation related to potential abuse involving Resident A and their spouse.
Complaint Details
The complaint involved Resident A's spouse making contact with the resident's face, giving unauthorized medication, feeding unsafe food, and causing verbal aggression and anxiety. Adult Protective Services were contacted. The facility had not updated the care plan or resident profile to reflect these issues, though verbal staff education was provided.
Findings
The facility failed to ensure safety and prevention of abuse for Resident A, including incidents where the spouse made physical contact, gave medication without authorization, fed unsafe food, and caused anxiety and aggression in the resident. The care plan and resident profile did not reflect these risks or direct staff interventions, despite verbal instructions given to staff to monitor and intervene.
Deficiencies (1)
Failure to protect residents from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Report Facts
Residents reviewed: 3
BIMS score: 7
Incident report date: Oct 9, 2025
Date of survey completed: Oct 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 2 | Provided information about verbal instructions to monitor Resident A when spouse was present | |
| Administrator | Provided information about verbal instructions to staff and awareness of incidents involving Resident A and spouse |
Inspection Report
Deficiencies: 6
Date: Aug 29, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident abuse prevention, timely reporting of abuse, wound care, dialysis care, medication management, and laboratory testing in the nursing facility.
Findings
The facility was found deficient in multiple areas including failure to protect residents from sexual abuse and inappropriate sexual behavior, failure to timely report suspected abuse, inadequate wound care practices, failure to ensure communication with dialysis providers, improper medication storage and labeling, and failure to complete physician-ordered laboratory tests.
Deficiencies (6)
Failed to protect residents from all types of abuse including sexual abuse and inappropriate sexual behavior involving two residents with cognitive impairment.
Failed to timely report suspected abuse and ensure proper investigation and notification to authorities for an occurrence of non-consensual intimate touching.
Failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, including improper wound care technique and failure to maintain sterile supplies.
Failed to ensure communication with dialysis provider and complete pre- and post-dialysis assessments for a resident requiring dialysis.
Failed to date medications when opened, failed to ensure treatments were placed in treatment cart, failed to keep medication carts clean and free from loose pills/debris, and failed to record temperature logs for emergency drug kit/narcotic refrigerator.
Failed to provide or obtain laboratory tests/services when ordered and promptly inform the ordering practitioner of the results, including missing labs for Vitamin D, Hepatic Function, Ammonia, and Depakote levels.
Report Facts
Residents reviewed: 19
Residents reviewed: 3
Residents reviewed: 1
Residents reviewed: 5
Medication carts reviewed: 4
Medication storage rooms reviewed: 1
Missing temperature log dates: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided interviews regarding sexual abuse incidents, medication administration, dialysis communication, and medication room security | |
| Licensed Practical Nurse (LPN) 6 | Interviewed regarding sexual abuse protocols and medication administration | |
| Licensed Practical Nurse (LPN) 10 | Interviewed regarding sexual abuse definitions and reporting requirements | |
| Registered Nurse (RN) 7 | Observed and interviewed regarding wound care procedures | |
| Registered Nurse (RN) 8 | Interviewed regarding dialysis communication and documentation | |
| Licensed Practical Nurse (LPN) 5 | Interviewed regarding medication cups placement | |
| Director of Nursing (DON) | Interviewed regarding medication cart cleanliness, temperature logs, laboratory testing, and medication room security |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 23, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging inadequate supervision and care to prevent falls for Resident B, who experienced two falls resulting in a fractured leg.
Complaint Details
This citation relates to Complaint IN00460903. The complaint alleged inadequate supervision and care to prevent falls for Resident B, resulting in injury.
Findings
The facility failed to ensure the root cause of falls was properly assessed and that care plan interventions were developed and implemented to prevent further falls for Resident B. The care plans lacked specific details on assistance required, weight bearing status, ambulation ability, and scheduled toileting plans. Interviews and record reviews confirmed that the resident's increased fall risk related to toileting needs and incontinence was not adequately addressed in the care plan.
Deficiencies (1)
Failed to ensure the root cause of falls was assessed and care plan interventions were developed and implemented to prevent further falls for Resident B.
Report Facts
Falls: 2
Date of falls: May 29, 2025
Date of falls: May 31, 2025
Date of care plan interventions: Jun 2, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Interviewed regarding investigation of falls and development of fall interventions. | |
| Assistant Administrator | Interviewed regarding investigation of falls and development of fall interventions; provided facility fall policy. | |
| Unit Manager | Interviewed regarding investigation of falls and development of fall interventions. | |
| Rehabilitation Therapy Director | Interviewed regarding Resident B's need for staff assistance for ambulation. | |
| Physical Therapist | Interviewed regarding Resident B's need for staff assistance for ambulation. | |
| Nurse Practitioner (NP) | Notified after Resident B's fall and administered pain medication. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 29, 2025
Visit Reason
The inspection was conducted following a complaint alleging that the facility failed to timely assess and notify the physician of acute changes in a resident's condition, did not follow advance directives for hospital transfer, and did not follow physician orders for medication administration for Resident B.
Complaint Details
Complaint IN00460004 related to Resident B's care and death. The complaint alleged failure to timely assess and send the resident to the hospital per advance directives, inconsistent medication administration, and lack of notification to physician and family of acute changes. The complaint was substantiated by findings.
Findings
The facility failed to ensure timely assessment and physician notification following Resident B's acute condition changes, did not follow advance directives for hospital transfer, and inconsistently administered and documented medication orders. The resident's family alleged that these failures contributed to Resident B's death.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including timely assessment and physician notification following acute changes in condition, adherence to advance directives, and following physician orders for medication.
Report Facts
Medication administration days: 8
Medication held without documentation: 1
Diarrhea episodes: 7
Pain rating: 7
Blood pressure readings: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner | Nurse Practitioner | Provided progress notes and was interviewed regarding Resident B's condition and medication orders. |
| Executive Director | Executive Director | Interviewed regarding knowledge of events during Resident B's stay. |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies and staff expectations for notification of changes. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 10, 2025
Visit Reason
The inspection was conducted to investigate a complaint related to the facility's failure to provide appropriate dementia care and services to residents diagnosed with dementia.
Complaint Details
This citation relates to Complaint IN00454576.
Findings
The facility failed to ensure adequate dementia care and services for 2 of 3 residents reviewed (Resident J and Resident K). Observations showed lack of activities, insufficient staff engagement, and inadequate behavioral interventions on the secured Memory Care Unit. Care plans lacked specific dementia programming and did not address residents' behavioral needs adequately.
Deficiencies (1)
Failure to provide appropriate treatment and services to residents diagnosed with dementia, including lack of activities and insufficient behavioral interventions.
Report Facts
Activities provided: 0
Activities provided: 2
Activities provided: 1
Activities provided: 3
Activities provided: 2
Activities provided: 2
Activities provided: 1
Activities provided: 1
Activities provided: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 5 | Registered Nurse | Interviewed about dementia unit activities and resident behaviors; indicated no specific dementia programming and limited behavioral interventions. |
| LPN 7 | Dementia Unit Manager | Interviewed about personnel changes and ongoing review of dementia program to improve activities and behavior modifications. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 10, 2024
Visit Reason
The inspection was conducted as an annual survey of Lutheran Life Villages to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 8, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Lutheran Life Villages.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Deficiencies: 1
Date: Oct 2, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care standards, specifically to assess whether residents received appropriate oxygen therapy as ordered by physicians.
Findings
The facility failed to ensure that one resident (Resident 74) received oxygen therapy at the prescribed flow rate of 2 liters per minute, as the resident was observed receiving oxygen at 3 liters per minute. The deficiency was noted based on observations, record reviews, and interviews with nursing staff and the Director of Nursing.
Deficiencies (1)
Failed to ensure a resident received appropriate oxygen therapy at the prescribed flow rate.
Report Facts
Residents reviewed for respiratory care: 2
Oxygen flow rate ordered: 2
Oxygen flow rate observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Interviewed regarding Resident 74's oxygen flow rate |
| Director of Nursing | Interviewed regarding Resident 74's oxygen flow rate order and actual flow rate |
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